Abstract
Anterior cable reconstruction (ACR) using the long head of the biceps tendon (LHBT) was developed to place at the native superior capsule attachment site for large to massive rotator cuff tears (LMRCTs) with anterior cable disruption. In this study, we investigated whether ACR for reinforcement before ARCR prevented retear after arthroscopic rotator cuff repair (ARCR), especially in cases of LMRCTs with anterior cable disruption. A total of 125 patients who underwent arthroscopic rotator cuff repair (ARCR) for LMRCTs were retrospectively enrolled. To assess the benefit of ACR with LHBT, all data were compared with those after ARCR alone. As a result, ACR with LHBT showed satisfactory clinical and radiologic outcomes in comparison with conventional ARCR only technique. ACR with LHBT prevented retear after ARCR and improved the AHD, although There was no difference of clinical outcomes between two groups.
Keywords: Rotator cuff, Long head of biceps tendon, Rotator cable, Acromiohumeral distance, Retear
1. Introduction
Large to massive rotator cuff tears (LMRCTs) are often difficult to repair owing to chronic wear of the tendon, severe retraction, muscle atrophy, and fatty degeneration.1, 2, 3 In most cases, arthroscopic rotator cuff repair (ARCR) provides satisfactory clinical results.4,5 However, patients are not satisfied with the results, and the retear rate is up to 94.4%, so effectively treating LMRCTs remains a challenge for shoulder surgeons.6
Most risk factors for rotator cuff retear are related to tendon and muscle degeneration and are due to age, overuse before initial tear, and disuse after initial tear.7 For the repair of severely degenerated rotator cuff tendons, high tension is needed to fix the torn tendons to the greater tuberosity, owing to the large defect of the torn tendons, the shortening of the tendon tissue, and severe retraction.4, 5, 6, 7, 8 Moreover, such degenerated tendons are weaker and thinner than native tendons, resulting in lower tensile strength.9 Therefore, when tendinopathic tendons are repaired, the increased tension in the weakened tendon tissue leads to a high rate of retear in rotator cuffs.7
For LMRCTs, superior capsular reconstruction (SCR) has been described.10,11 However, for tears that do not allow anatomic restoration, such as medialized repairs or partial repairs, any repair or remaining defect requires the tendon to act as both a tendon and ligament; the residual dynamic tendon may be prone to insufficient healing or recurrent injury given the relative lack of static ligamentous support.11,12 Partial repairs have had less predictable results, and some tears are simply irreparable, leaving large defects.13,14 In these cases, the dynamic tendon would preferably be supported by a static structure that would provide ligamentous support.13,14 Ideally, any such supporting structure would help maintain glenohumeral congruency, acting to prevent humeral head superior migration, but would not overconstrain the joint.13,14
In 2018, Part et al.14 introduced that anterior cable reconstruction (ACR) with the long head biceps tendon (LHBT). Because, LHBT could act as a ligamentous structure in this setting for several reasons: its proximal attachment on the glenoid is close to the native capsular attachment site and would not require glenoid fixation, obviating the risks for graft healing insufficiency and potential implant failures.14 As a result, they reported that ACR using LHBT biomechanically normalized superior migration and subacromial contact pressure, without limiting range of motion.
To the best of our knowledge, no in vivo studies have clinical and radiological outcomes of ACR using LHBT for LMRCTs with anterior cable disruption. We recently modified the technique for ACR using LHBT to provide reinforcement in repairable LMRCTs with anterior cable disruption. In this surgery, ACR using LHBT for reinforcement may improve superior shoulder stability, and it may increase tendon strength by increasing tendon thickness. Consequently, ACR using LHBT for reinforcement may lower the retear rate of repaired rotator cuff tendons.
Therefore, the aim of this study was to analyze whether ACR using LHBT with ARCR improved cuff integrity for LMRCTs with anterior cable disruption. Our hypothesis was that ACR using LHBT would prevent postoperative retear after ARCR, and increase the acromio-humeral distance (AHD).
2. Method
Following Institutional Review Board exempt approval, a total of 125 patients who underwent arthroscopic rotator cuff repair (ARCR) for LMRCTs were retrospectively enrolled in the study from June 2016 to December 2019. The inclusion criteria for the study were symptomatic rotator cuff tears, defined as a LMRCTs confirmed on preoperative magnetic resonance image (MRI) as more than 2 cm tear size and anterior cable disruption (it was determined that a disruption of the anterior rotator cable was present if the supraspinatus tendon was completely detached from the anterior attachment site and the LHBT along the bicipital groove was exposed in the subacromial space during arthroscopy).15,16 ACR using LHBT was used in the final 41 cases, and only ARCR was used in the first 84 consecutive cases. We evaluated clinical and radiologic outcomes of the patients who were followed for at least 12 months after the surgery. The exclusion criteria were complete rupture of LHBT on preoperative MRI, neuromuscular disease, shoulder instability, previous surgery on the affected shoulder, irreducible LMRCTs. Reducibility of the torn rotator cuff tendons was assessed during diagnostic arthroscopy.
2.1. Surgical technique
Patients can be positioned in the operating room as per surgeon preference for arthroscopic rotator cuff repair; either the lateral decubitus or the beach chair position can be used. A diagnostic shoulder arthroscopy of the glenohumeral joint is performed with standard anterior, posterior, and lateral portal placement, visualizing the extent of the rotator cuff tear and anterior cable disruption, as well as the integrity of the LHBT. A disrupted LHB tendon or a retracted rotator cuff tear with inability to adequately mobilize would preclude proceeding with the proposed surgical technique.
Biceps tenodesis is then performed at the 1 cm superior aspect of the bicipital groove and this is achieved by percutaneously placing triple loaded Y-Knot® RC All-Suture Anchor (ConMed, New York, NY, USA). The first suture limb should pass through the anterior LHBT to move the tendon posteriorly. The second suture limb wraps around the LHBT and is then tied. The third suture limb passes through the LHBT to secure fixation at the anchor site. Owing to shifting and fixing the LHBT at the anchor site, the LHBT from the anchor to the glenoid attachment site serves as an ACR (Fig. 1). The LHBT from the anchor site to the bicipital groove uses a biceps tendon interposition between the RCT and humeral head, aiding in biological healing and strengthening poor quality rotator cuff tendons.
Fig. 1.
Arthroscopic view of the left shoulder from the lateral portal, beach chair position. Biceps tenodesis at the. superior bicipital groove has been performed with incorporation of anterior rotator interval tissue. The long head of the biceps tendon remains attached to the supraglenoid tubercle. B; the long head of the biceps tendon, RC; rotator cuff, H; humerus.
After ACR is accomplished, a standard, double-row, transosseous equivalent technique (ConMed, New York, NY, USA), with medial row knot-tying, is performed to achieve rotator cuff repair and footprint compression of the remaining tendon tissue (Fig. 2). If mobility of the tissue precludes transosseous equivalent repair over the greater tuberosity, single-row repair to the medial edge of the greater tuberosity can be performed. All patients undergo a final subacromial decompression, including acromioplasty.
Fig. 2.
Arthroscopic view of the left shoulder from the lateral portal, beach chair position. Completed rotator cuff transosseous equivalent repair with anterior cable reconstruction using long head of the biceps tendon. RC; rotator cuff, H; humerus.
2.2. Rehabilitation
Postoperative restrictions and rehabilitation are similar to standard rotator cuff repair protocols. The protocol at the authors’ institution focuses on progressive range of motion in supine position and pendulum exercises for the first 4 weeks, active assisted range of motion and gentle isometrics at 4–8 weeks. and gentle progressive resistive exercises after 8 weeks. The return to sport phase is usually initiated after 6 months.
2.3. Functional and radiological evaluation
American Shoulder and Elbow Surgeons (ASES) scores, and Visual Analog Scale (VAS) pain score (0–10) were checked preoperatively; at postoperative 3 months, 6 months, and 12 months. A goniometer was used to evaluate the range of motion (ROM) of forward flexion (FF), and external rotation at the side (ER). Internal rotation (IR) was evaluated as the highest vertebral level that the tip of the thumb could reach in a sedentary position. The levels of the vertebra were numbered serially from below the sacrum (level 0) to the 7th thoracic vertebra (level 12). ROM was evaluated by a physician who had no information on the enrolled patients. They were reassessed at final follow-up; postoperative complications were recorded also.
Plain anteroposterior radiographs and magnetic MRI were used for radiological evaluation. The acromiohumeral distance (AHD) was checked preoperatively and at last follow-up. The AHD was the smallest distance from the superior aspect of the humeral head to the inferior surface of the acromion. MRI was performed preoperatively and 12 months after surgery to evaluate the integrity of the rotator cuff. The Sugaya classification17 was used to evaluate retear patterns of the repaired rotator cuff, and Sugaya classification types 4 and 5 were considered retears. Radiological evaluation was evaluated by a physician who had no information on the enrolled patients.
2.3.1. Statistical analysis
To determine the normal distribution of continuous data, a Kolmogorov–Smirnov test was performed. Continuous variables were analyzed using an independent t-test, and noncontinuous variables were analyzed using a Pearson chi-square test. All statistical analyses were performed using the Statistical Package for Social Sciences version 25.0 (SPSS,Inc., an IBM Co., IL, USA). Statistical significance was considered at a p value < 0.05 for all analyses.
3. Results
3.1. Clinical and radiological outcomes
VAS pain and ASES scores increased significantly after ACL with LHBT group (VAS, 4.1 preoperatively to 1.6 postoperatively; ASES, 43.2 to 91.9) and ARCR only group (VAS, 3.9 to 1.7; ASES, 45.2 to 92.3). However, VAS and ASES scores did not differ significantly between ACL with LHBT group and ARCR only group before or after surgery (Table 2).
Table 2.
Clinical and Radiologic outcomes between the two groups.
| Variable | ACR with LHBT (n = 41) | ARCR only (n = 84) | p-value |
|---|---|---|---|
| VAS pain | |||
| Preoperative | 4.1 ± 2.1 | 3.9 ± 1.9 | 0.66 |
| Postoperative | 1.6 ± 1.5 | 1.7 ± 1.8 | 0.26 |
| p-value | 0.02 | 0.01 | |
| ASES score | |||
| Preoperative | 43.2 ± 21.6 | 45.2 ± 18.9 | 0.66 |
| Postoperative | 91.9 ± 7.5 | 92.3 ± 8.1 | 0.27 |
| p-value | <0.0001 | <0.0001 | |
| Active forward elevation | |||
| Preoperative | 128.6 ± 42.1 | 131.2 ± 38.4 | 0.75 |
| Postoperative | 167.4 ± 23.4 | 166.1 ± 25.2 | 0.28 |
| p-value | <0.0001 | <0.0001 | |
| Active external rotation | |||
| Preoperative | 41.8 ± 18.2 | 39.1 ± 22.5 | 0.39 |
| Postoperative | 49.3 ± 13.2 | 50.1 ± 16.6 | 0.37 |
| p-value | 0.04 | 0.02 | |
| Active internal rotation | |||
| Preoperative | L3 | L2 | 0.37 |
| Postoperative | L1 | T12 | 0.08 |
| p-value | <0.0001 | <0.0001 | |
| Acromiohumeral distance, mm | |||
| Preoperative | 7.0 ± 2.3 | 7.1 ± 2.6 | 0.30 |
| Postoperative | 9.2 ± 1.9 | 8.1 ± 2.4 | 0.01 |
| p-value | <0.0001 | <0.0001 | |
| Retear, % | 2/41 (4.9%) | 6/84 (7.1%) | 0.07 |
ASES: American Shoulder and Elbow Surgeons, KSS: Korean shoulder score, AHD: Acromiohumeral distance.
Shoulder ROM also improved significantly after ACL with LHBT group and ARCR only group, however Postoperative active ROM did not differ significantly between ACL with LHBT group and ARCR only group before or after surgery (Table 2).
AHD significantly increased after surgery in both groups (p < 0.0001), and postoperative AHD of ACR with LHBT group was larger than that of ARCR only group, although there was no difference of preoperative AHD between two groups (Table 2).
Retear rate of ACR with LHBT group was significantly lower than that of ARCR only group (p = 0.02, Table 2), Although there was no difference of preoperative anterior-posterior tear size, medial-lateral tear size, and Goutallier classification (Table 1).
Table 1.
Demographic data.
| Variable | ACR with LHBT (n = 41) | ARCR only (n = 84) | p-value |
|---|---|---|---|
| Mean age | 61.9 ± 9.8 | 62.6 ± 8.2 | 0.81 |
| Gender (Male: Female) | 13 : 18 | 36 : 48 | 0.72 |
| Dominant arm: Non-dominant arm | 23:18 | 47: 37 | 0.62 |
| Height (cm) | 167.3 ± 9.6 | 168.1 ± 11.8 | 0.19 |
| Weight (kg) | 64.9 ± 10.9 | 65.2 ± 12.1 | 0.39 |
| Body mass index | 23.1 ± 3.8 | 23.0 ± 2.7 | 0.96 |
| Smoking: Non-smoking | 12 : 29 | 21 : 62 | 0.64 |
| ASA class (1:2:3) | 30 : 11: 1 | 62 : 19: 3 | 0.79 |
| Anterior-posterior tear size, cm | 3.1 ± 0.6 | 3.0 ± 0.5 | 0.72 |
| Medial-lateral tear size, cm | 2.9 ± 0.7 | 3.1 ± 0.6 | 0.78 |
| Goutallier classification | |||
| Supraspinatus | 2.8 (2–4) | 2.6(2–4) | 0.24 |
| Infraspinatus | 2.1 (1–4) | 2.0 (1–4) | 0.16 |
| Teres minor | 0.1 (0–1) | 0.1 (0–1) | 0.45 |
| Subscapularis | 0.7 (0–4) | 0.8 (0–4) | 0.61 |
| Mean follow-up (month) | 18.7 ± 4.2 | 15.6 ± 2.1 | 0.82 |
4. Discussion
The primary aim of this study was to assess the clinical and radiological outcomes of ACR using LHBT for LMRCTs with anterior cable disruption. Supporting our initial hypothesis, retear rate of ACR with LHBT group was significantly lower than that of ARCR only group, and postoperative AHD of ACR with LHBT was larger than that of ARCR only, although there was no difference of preoperative AHD between two groups.
The rotator cable shields the rotator crescent, the site where most rotator cuff tears initiate, from stress.12, 13, 14, 15, 16, 17, 18 It allows the supraspinatus to transmit its muscle force to the humerus even in the presence of a tear, similar to the cables found in suspension bridges.19 Therefore, it is thought that rotator cuff tears involving the anterior or posterior attachment of the rotator cable lead to increased stress on the crescent tissue, resulting in propagation of the rotator cuff tear.20
In 2014, Namdari et al. reported that disruption of the anterior supraspinatus tendon was associated with a greater tear size and more advanced supraspinatus muscle degeneration in the setting of painful small- and medium-sized rotator cuff tears.21 In 2017, Cho et al. also described that the retear rate was significantly higher in patients with a tear involving the anterior attachment of the rotator cable. In 2018, Part et al. reported that ACR using autologous biceps tendon biomechanically normalized superior migration and subacromial contact pressure, without limiting range of motion. This cadaveric study provides biomechanical proof that ACR with LHBT can potentially provide a more robust repair construct and help to prevent the known complications of rotator cuff tears with anterior cable disruption. Therefore, we thought that ACR with LHBT has the potential to improve patient outcomes after rotator cuff repair surgery.
The choice of LHBT as an autograft source to ACR is logical and adds minimal patient morbidity, given the close proximity of the LHBT to the rotator cuff. Furthermore, concomitant LHBT pathology is quite common in the setting of rotator cuff tears, and tendon sacrifice via tenotomy or tenodesis is routinely performed.14, 15, 16, 17, 18, 19, 20, 21, 22 The biomechanical study of SCR using the LHBT, insisted that SCR with an LHBT auto-graft was potentially even stronger than SCR with a TFL auto-graft in the prevention of superior humeral migration.23 Recently, several clinical studies have described using the LHBT to augment rotator cuff repair.22, 23, 24 In these previous studies, the technique of management of the end of the LHBT was differ according to the sacrifice or not. In our technique, we just re-positioned the LHBT on the greater tuberosity. Thus, we could obtain the native tension of the LHBT, which forced to the humeral head downward. To our knowledge, this is the first in vivo study of ACR with LHBT through comparison with only ARCR. As a result, ACR with LHBT technique showed lower retear rate and larger restoration of AHD than them of ARCR only technique.
The present study has several limitations. First, this study was conducted as a non-randomized retrospective study. The data for the two groups in this study were collected from different periods to eliminate patient selection bias, but doing so might have influenced the clinical results. Second, only 41 patients were included in the ACR with LHBT group. A small sample size often leads to type II error due to the low statistical power, although a retrospective power analysis concluded that a minimum of 16 cases were required in each group to identify a 10% difference between the groups, with an α level of 0.05 and β value of 0.80. Third, the results are short term. We could not evaluate long-term outcomes of ACR with LHBT. Therefore, we cannot confirm whether ACR with LHBT is feasible as a long-term joint preservation option.
5. Conclusion
ACR with LHBT showed satisfactory clinical and radiologic outcomes in comparison with conventional ARCR only technique. ACR with LHBT prevented retear after ARCR and improved the AHD, although There was no difference of clinical outcomes between two groups.
Level of evidence
Level III, retrospective study.
Funding
There is no funding source.
Ethical approval
This article does not contain any studies with human participants or animals performed by any of the authors.
Declaration of competing interest
The authors declare that they have no conflict of interest.
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